Health New England

HNE Provider

Forms

These PDF formatted forms are to be used by participating physicians and providers.

Forms [+]

Asthma Control Tests for Children and Adults

Notification Form – Here to There Program
(Certain commercial groups only)

Reportable Adverse Incident Form
(HNE Be Healthy Only)

Primary Care Clinician (PCC) Plan Community Support Program Referral Form

Pharmacy Forms

Appeals [+]

Request for Claim Review Form

Request for Claim Review Guide

Behavioral Health [+]

Applied Behavior Analysis (ABA)
Diagnostic And Functional Assessment Prior Authorization Request Form

Applied Behavior Analysis (ABA)
Extended Service Request Form

Applied Behavior Analysis (ABA)
Initial Request Form

Combined MCE Behavioral Health Provider/Primary Care Provider Communication
(HNE Be Healthy Only)

Dialectical Behavior Therapy Extended Review

Dialectical Behavior Therapy Initial Review

Family Stabilization Team Initial Review

Family Stabilization Team Discharge Summary Form

Family Stabilization Team Concurrent Review Form

Inpatient Psychiatric Clinical Review Information

Inpatient Detoxification Clinical Review Information

Intensive Outpatient Program Clinical Review Information

MassHealth Daily Adverse Incident Report (HNE Be Healthy Only)

Member Authorization for Behavior Health Provider and Behavior Health Provider Communication

Member Authorization for PCP and Behavior Health Provider Communication

Neuropsychological and Psychological Testing
Prior Authorization Request

Outpatient MH/SA Treatment Request

Partial Hospital Program Clinical Review Information

Referral to Out of Network Provider

Repetitive Transcranial Magnetic Stimulation (RTMS)
Prior Authorization Request

PHQ-9 Depression Screening Tool

Children's Behavioral Health Initiative [+]

Combined MCE Behavioral Health Provider/Primary Care Provider Communication
(HNE Be Healthy Only)

Claims [+]

835 Health Care Electronic Remittance Advice (ERA) New Request

Request for Claim Review Form

Request for Claim Review Guide

Statement of Understanding

Clinical Request Forms [+]

Absorbency Product Form
(HNE Be Healthy Only)

Breast and Ovarian Cancer Screening by Molecular Testing Prior Authorization Request

Care Management Request

Combined MCE Behavioral Health Provider/Primary Care Provider Communication
(HNE Be Healthy Only)

Infertility Treatment Prior Approval Request

Obstetrical Pre-Registration

Prior Approval Request

Home Infusion (HI) Initial Prior Approval Request

Medical Necessity Review Form For Enteral Nutrition Products
(HNE Be Healthy Only)

Universal Health Plan/Home Health Authorization